The Remains of the Profession, or What the Butler Knew

Forty percent to 50% of physicians today are salaried employees (1). The rapid transformation of the independent practitioner into the employee-practitioner has prompted widespread debate about the potential erosion of medical professionalism, especially physicians' autonomy and integrity (2-5). This essay was prompted by a rereading of The Remains of the Day(6), Kazuo Ishiguro's brilliant novel about an English butler's moral awakening, against the background of these concerns.

Traditionally, professional autonomy was defined as control over work practices and values; in most discussions of the issue, this is still the sense in which the term is used. Authentic professional autonomy thus demands not only control over one's work, but acceptance of ethical accountability—the flip side of independence. Can such accountability, or integrity, survive in a corporate setting? Certainly, employees can be professionals; the church, nursing, engineering, law, and, increasingly, medicine offer many instances of the phenomenon. Professionalism has never required self-employment. But what are the implications for professional integrity when “service,” one of the traditional pillars of professionalism, is performed by a “service worker” (7)? And can physicians maintain their integrity if they are employed by a corporation in which integrity is completely lacking?

The musings of Stevens, protagonist of The Remains of the Day, uncomfortably echo the experiences reported by many physicians in today's health care institutions. Stevens intones the words “profession” and “professional” six times within the first eight pages of text; such references persist throughout the book. His solemn phrases—“those of our profession,” “exemplary professionalism,” and “professional standards”—rest uneasily with our knowledge that Stevens is a butler. Beneath the novel's tragicomic veneer lies a stark meditation on the tension between professional integrity and unthinking loyalty.